Providers

Provider Portal Registration Form

Only one use per office. We suggest a generic login

First Name:
Last Name:
Address 1:
Address 2:
City:
State:
Zip:
Phone:
Fax:
Your E-Mail:
Challenge Question: Will be used for Password Changes
Challenge Response: Will be used for Password Changes
User ID: Used to login
Password: Used to login
TIN Number:
Authorized by: Insert First Name, Last Name

As a provider of dental/medical procedures, it is your responsibility to ensure that user passwords are changed in the event of staff turnover in order to protect patient PHI.

Health Insurance Las Vegas Las Vegas Pregnancy Las Vegas Minimally Invasive Surgery Web Design Las VegasLocksmith Las Vegas